Makindo Medical Notes

Constipation in children is very common, accounting for up to 25% of paediatric GI referrals. It is usually functional (dietary, behavioural, or lifestyle-related) but may rarely be organic (neurological, endocrine, anatomical). Early recognition and treatment prevent chronic complications such as faecal impaction and encopresis.

⚠️ Causes of Constipation

• Functional (most common) 🥦💧
  • Low fibre diet, inadequate fluid intake.
  • Withholding behaviour (fear of pain, unfamiliar toilets).
  • Toilet training issues.
• Organic (less common) 🧬
  • Hirschsprung disease → congenital absence of ganglion cells.
  • Hypothyroidism → ↓ gut motility.
  • Cystic fibrosis → inspissated stools, meconium ileus.
  • Spinal cord lesions (e.g. spina bifida).
  • Allergy → cow’s milk protein allergy in infants.
• Medication-related 💊
  • Iron supplements, opioids, antacids, anticonvulsants.

🧾 Clinical Presentation

• Symptoms → infrequent stools, hard/painful defecation, abdominal pain, faecal incontinence (encopresis).
• Examination:
  • Abdominal distension, palpable stool mass.
  • Rectal exam (if red flags): faecal impaction, anal abnormalities.
  • Growth and development → poor growth or neuro delay suggests organic disease.

🚨 Red Flags (Think Organic)

• Delayed passage of meconium (>48h after birth).
• Failure to thrive or weight loss.
• Bilious vomiting, abdominal distension.
• Abnormal neuro exam (spina bifida, lower limb weakness).
• Rectal bleeding (other than fissures).

🛠️ Management

Treatment is stepwise → disimpaction → maintenance → long-term lifestyle support.

• Lifestyle & Diet 🥦🥕
  • High-fibre diet (fruit, vegetables, whole grains).
  • Adequate hydration (water, not sugary drinks).
  • Encourage regular physical activity.
• Behavioural Therapy ⏰
  • Toilet sitting after meals (gastrocolic reflex).
  • Positive reinforcement & reward charts.
  • Avoid punishment → worsens withholding behaviour.
• Laxatives 💊
  • Osmotic → polyethylene glycol (Movicol) or lactulose (first-line).
  • Stimulant → senna, bisacodyl (short-term if osmotics fail).
  • Lubricant → mineral oil (caution aspiration risk).
  • Enemas/suppositories → for impaction, under supervision.
• Underlying causes 🔍
  • Refer to specialists if Hirschsprung disease, hypothyroidism, or cystic fibrosis suspected.

📈 Monitoring & Follow-Up

• Regular review of stool frequency, consistency (Bristol stool chart).
• Parental education to avoid stopping laxatives too early (risk of relapse).
• Check growth, nutrition, and psychosocial wellbeing.

🧠 Exam Pearls

• 💡 Most constipation in children is functional — organic causes are rare but must be ruled out if red flags present.
• 💡 Encopresis = overflow incontinence from faecal impaction.
• 💡 Movicol is first-line for both disimpaction and maintenance.

🖼️ Diagrams

📚 References

• NHS National Clinical Constipation Pathway
• NICE CG99: Constipation in Children and Young People